Review Article

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Strategies to optimize enteral feeding and nutrition in the critically

ill child: a narrative review
Sharon Y. Irving1,2^, Ben D. Albert3,4, Nilesh M. Mehta3,4, Vijay Srinivasan2,5
1
University of Pennsylvania School of Nursing, Philadelphia, PA, USA; 2Children’s Hospital of Philadelphia, Philadelphia, PA, USA; 3Boston
Children’s Hospital, Boston, MA, USA; 4Harvard Medical School, Boston, MA, USA; 5University of Pennsylvania Perelman School of Medicine,
Philadelphia, PA, USA
Contributions: (I) Conception and design: All authors; (II) Administrative support: SY Irving; (III) Provision of study materials or patients: None; (IV)
Collection and assembly of data: All authors; (V) Data analysis and interpretation: None; (VI) Manuscript writing: All authors; (VII) Final approval of
manuscript: All authors.
Correspondence to: Sharon Y. Irving. University of Pennsylvania School of Nursing; Children’s Hospital of Philadelphia, Philadelphia, PA, USA.
Email: ysha@nursing.upenn.edu.

Background and Objective: The provision of nutrition therapy is an integral component of care
for the critically ill child. Essential factors to consider include the child’s evolving metabolic needs, age,
underlying disease, co-morbidities and severity of illness. The stress response has a significant impact on
energy requirements and protein utilization during critical illness. To ameliorate the impact of the stress
response, nutrition therapy is a crucial aspect of care. Scientific support for early enteral nutrition is strong,
yet application in clinical practice remains challenging. The aim of this narrative review is to discuss
the physiology of metabolic derangements that occur during critical illness, outline optimal nutrition
prescription, and discuss benefits of early enteral nutrition. Considerations of special populations, such as the
surgical patient, and the patient requiring vasoactive medications will also be discussed.
Methods: The authors reviewed literature pertinent to the topic area, with incorporation of their collective
expert opinion on topics related to nutrition in critically ill children. A structured appraisal of the literature
was not conducted.
Key Content and Findings: Enteral feeds should be initiated as soon as safely possible with advancement
in a careful stepwise manner. The post-operative surgical patient presents unique challenges to nutrition
therapy. Enteral nutrition for children requiring vasoactive medications can be safe, well-tolerated and
beneficial.
Conclusions: Despite the heterogeneity of age, diagnosis, overall presentation at time of illness onset
and interventions in the PICU setting, evidence suggests that enteral nutrition is associated with improved
clinical outcomes, decreased length of hospitalization and decreased mortality in critically ill children.
Strategies to optimize enteral feeding in critically ill children must consider the severity of illness, the child’s
nutritional status, include determination of energy and protein needs and have clear criteria for monitoring
feeding tolerance with the child’s changing clinical status. Future inquiry must explore the impact of enteral
nutrition in various phases of pediatric critical illness and determine optimal approaches to assessment,
prescription, delivery and evaluation of feeding tolerance in this population.

Keywords: Pediatric nutrition; pediatric critical care; enteral nutrition; critical illness; perioperative nutrition;
Enhanced Recovery after Surgery (ERAS)

Received: 19 January 2021; Accepted: 12 March 2021; Published: 28 February 2022.

doi: 10.21037/pm-21-6
View this article at: http://dx.doi.org/10.21037/pm-21-6

^ ORCID: 0000-0003-2967-0721.

© Pediatric Medicine. All rights reserved. Pediatr Med 2022;5:9 | http://dx.doi.org/10.21037/pm-21-6

Page 2 of 12 Pediatric Medicine, 2022

Introduction children.

Enteral nutrition (EN) is the preferred method of providing

nutrition therapy in critically ill children with a functional Methods
gastrointestinal (GI) tract. EN has been shown to be safe,
Collaboratively, the authors reviewed literature pertinent to
well-tolerated and associated with improved outcomes.
the topic of interest and combined this with their collective
Literature has associated decreased hospital acquired
expert opinion on nutrition therapy in pediatric critical
infections, increased ventilator-free days, decreased length illness to develop this summation in a narrative review
of stay, and decreased mortality with EN during critical format. A structured appraisal using scoping, systematic,
illness (1-4). Despite this evidence, challenges related to or meta-analysis review methodology was not employed to
optimal provision of nutrition therapy in this population construct this review.
remain. Current guidelines recommend early enteral
nutrition (EEN) as a core component of best practices
for care delivery (1,5-8). While these recommendations Determining nutritional needs in critically ill
emphasize the benefit(s) of EN in critically ill children, children
questions persist regarding timing, route, and rate of enteral Nutrition therapy during critical illness is expected to offset
feeding as well as determining acceptable targets for feed the burden of the metabolic stress response and prevent loss
volume, energy and protein intake. of lean mass to improve clinical outcomes. This includes
The goal of nutrition therapy during critical illness prudent prescription of nutrients individualized to the
is to meet the patient’s basal metabolic needs, support patient and the phase of illness, and provide nutrients in
the body in response to stress and illness, and prevent an efficient and safe manner (Figure 1). There have been
the ongoing loss of lean body mass (4,9,10). The aim of several key advances to improve understanding of energy
this review is to discuss the metabolic derangements that and protein requirements. However, the amount that is
occur during critical illness, the benefits of EEN and the most associated with improved clinical outcomes is not yet
practical strategies to optimize nutrition in critically ill determined. Hence, there remains significant uncertainty

Offset the burden

of metabolic stress
response

Improve
patient-centered
Outcomes

Preserve Avoid complications

muscle mass of EN and PN

Figure 1 Goals of nutrition therapy. Meeting metabolic needs, will offset the stress response and avert loss of lean mass and fat, improving
outcomes from critical illness. Legend: EN, enteral nutrition; PN, parenteral nutrition.

© Pediatric Medicine. All rights reserved. Pediatr Med 2022;5:9 | http://dx.doi.org/10.21037/pm-21-6

Pediatric Medicine, 2022 Page 3 of 12

in the best approach to prescribing energy and protein, measured by IC. Importantly, a study of 500 critically ill,
especially during the early phase of pediatric critical illness. mechanically ventilated children, demonstrated that a higher
percentage of goal energy intake was delivered via the
enteral route and was significantly associated with lower 60-
Energy requirement in critical illness
day mortality [odds ratio (OR) for increasing energy intake from
Significant improvements in surgical, anesthetic and 33.3% to 66.6%, 0.27 (0.11, 0.67), P=0.002] (2). Comparatively,
intensive care therapies may be responsible for a more the same study demonstrated higher mortality in patients
subdued metabolic state in critically ill patients (11,12). who received parenteral nutrition (PN) [OR 2.61 (1.3, 5.3),
This includes enhanced sedation and analgesic therapies, P=0.008] (2). Based on such observational data showing
improved patient respiratory ventilator synchrony, and associations between energy intake and outcomes when
advancements in bedside care. Studies that examine resting using predictive equations, current guidelines for nutrition
energy expenditure (REE) demonstrate an unpredictable delivery in critically ill children recommend targeting two-
energy requirement in the heterogeneous pediatric intensive thirds (2/3rds) of the estimated REE during the first week
care unit (PICU) population (13). Energy requirements of illness (1,2).
evolve and may vary widely over the course of critical illness.
Recommended as a precise measure of REE in critically
Protein requirement in critical illness
ill children, indirect calorimetry (IC) should be used
whenever possible to guide energy prescription (14). Children with burns have similar clinical outcomes as
However, IC is not available at all centers, it requires critically ill children who experience a depletion of lean
significant resources and expertise, and may not be feasible muscle mass. Thermal or burn injury is illustrative of
in some patients during the acute phase of critical illness the burden and significance of protein catabolism, a key
(14,15). In the absence of measured REE by IC, standard characteristic of the metabolic stress response during
prediction equations such as the Schofield (16) and World critical illness (19). Postoperative measurement of protein
Health Organization (WHO) (17) are recommended turnover using the 15N-glycine based urinary end-product
to estimate REE (1,6). Developed from measurements enrichment technique in children following thoracic
in healthy children these equations should be used with surgery, demonstrates elevation of both protein synthesis
caution owing to the unpredictable nature of critical illness and breakdown (19,20). However synthetic rates of protein
and the metabolic alterations that occur. intake are unable to offset the degree of breakdown
Driven by a complex neuroendocrine cascade, the stress resulting in a net negative protein balance, and loss of
response incited during critical illness imposes a varied muscle mass (20). The critical depletion in lean mass from
energy burden characterized by alterations in carbohydrate, a prolonged stress response may be further exacerbated by
lipid, and protein metabolism (11). Predictive equations lack of intake of protein/amino acid substrate to support
cannot account for the dynamic nature of these alterations protein synthesis (21,22). Using measurements of isokinetic
and therefore risk under or overpredicting energy dynamometry (measures force and torque), the impact of
requirements in critically ill children (12,18). Attempts this loss of lean mass in pediatric burn patients resulted in a
to develop a predictive equation specifically for use with decrease in functional muscle assessments (19).
mechanically ventilated children have met with inaccuracies
and are not recommened (18). Additionally, the practice
Practical aspects of protein intake during
of adding disease, condition or activity-based stress factors
critical illness
to REE (estimated or measured) is also not recommended
when estimating energy needs in critically ill children (1,6). Protein delivery remains low in the acute phase of critical
Overall, it is prudent to be mindful of the risk of unintended illness (22-24). Findings from a study of more than
over or underestimation of energy requirements due to 1,200 children mechanically ventilated for greater than
reliance on inaccurate equations to estimate REE in the 48 hours, with median protein prescription of 1.9 g/kg/day,
PICU population. and delivery of 0.66 g/kg/day (38% of prescribed) showed
The optimal amount of energy necessary to improve protein intake (as a percentage of the prescribed goal) was
clinical outcomes is unknown (15,16). No current trials indirectly associated with increased 60-day mortality (22,25).
demonstrate the benefits of matching energy intake to REE Optimal protein delivery and intake is elusive and

© Pediatric Medicine. All rights reserved. Pediatr Med 2022;5:9 | http://dx.doi.org/10.21037/pm-21-6

Page 4 of 12 Pediatric Medicine, 2022

the ideal dose that results in improved clinical outcomes from observational and retrospective studies, and do not
unknown. Several small randomized trials compare high have the same evidence from randomized controlled trials
versus low protein dose and its impact on protein balance (RCTs) as adult studies (37-42). Globally, surveys of clinical
in pediatric critical illness (1). These trials are inconclusive practice demonstrate wide variation in approach to nutrition
due to being conducted in heterogeneous populations, therapy in critically ill children (8,43-45). Smaller studies
protein dose variation, route of delivery and inability to in this population have demonstrated beneficial changes
provide significant, consistent outcomes relationships. in nutritional biomarkers, nitrogen balance, inflammatory
Despite this, based on large observational studies and cytokines and immune mechanisms from provision of EEN
small trials, a minimum protein intake of 1.5 g/kg/day is (38-42,46,47).
recommended to maintain positive nitrogen balance and Defining EEN varies widely, from as early as six hours
prevent loss of lean mass in critically ill children (1,6). A to as late as 72 hours following onset of critical illness and
dose outcome relationship has only been established with PICU admission (48-51). Studies of EEN in critically ill
enteral protein intake. While it is currently more feasible to children vary and include the general PICU population as
consistently deliver increased doses of protein parenterally, well as children with disease specific states (48-56). Table 1
the benefit of increased parenteral protein delivery has not summarizes key studies of EEN in critically ill children.
been adequately demonstrated and recent data suggests EEN in general PICU population
harm with PN protein delivery during the initial 24 hours In general studies of EEN in PICU populations have
of PICU admission (24,26). reported a trend of fewer infections, a reduction in
measures of ICU dependency, less organ dysfunction and
decreased mortality (28,48,49). In addition, there may be
Strategies for energy and protein delivery
an association between an increased proportion of EEN
Once energy and protein needs are determined, enteral relative to goal energy prescription and decreased mortality,
feeds should be initiated as soon as possible with feed supporting a dose-response relationship (2,28,31,56,57).
advancement in a stepwise manner using feeding algorithms EEN in children with critical illness specific disease states
to attain target energy and protein intake (25-28). In In specific disease states as with a general PICU population,
vulnerable patients where the oral or enteral route EN is studies suggest EEN to be safe and beneficial even with
insufficient or not feasible, PN must be considered by the heterogeneity of diagnosis, presentation at time of illness
end of the first PICU week (29). However, such a pragmatic and interventions in the PICU setting. Retrospectives
approach, where it is initiated neither too early nor too late, studies where EEN was initiated in critically ill children
has not been tested in a well-designed trial. A strategy of with acute respiratory failure from acute lung injury and/
using an approach of EEN combined with pragmatic PN or acute respiratory distress demonstrated decreased length
aimed at delivering individualized macronutrient targets of stay, lower severity of respiratory failure, reduced use of
may be the most reasonable approach in certain patient vasoactive agents and decreased mortality (3,50,58).
populations. Evidence for EEN is lacking in children with septic
shock or other sepsis-associated illness and organ
Early initiation of EN in critically ill children dysfunction. In the absence of such evidence and without
Unlike adults, nutrition therapy in critically ill children contraindications to provision of EN, there is a clinical
must also account for differences in maintenance of preference to commence EEN within 48 hours of admission
nutritional status, safeguarding growth, and variances in in children with septic shock or sepsis-associated organ
metabolism as a function of age, size and state of illness dysfunction. Recent pediatric sepsis guidelines, support
(1,6). Adult and pediatric guidelines for nutrition therapy in initiation of EEN when appropriate, based on the child’s
critical illness recommend early initiation of enteral feeds clinical status (7).
to improve clinical outcomes (1,6,30,31). Enteral feeds Initiation of EEN in children with traumatic brain
promote and maintain GI mucosal integrity and function injury (TBI) is associated with better clinical and functional
(31,32). Studies suggest benefits include fewer infections outcomes (51,52). Recent studies favored EEN initiated in
and better healing, with overall improved short-term and within 72 hours and demonstrated that delayed initiation
long-term clinical outcomes (33-36). of EN (greater than 48 hours) in children with TBI was an
Pediatric data for the efficacy of EEN are largely derived independent risk factor for worse functional status at PICU

© Pediatric Medicine. All rights reserved. Pediatr Med 2022;5:9 | http://dx.doi.org/10.21037/pm-21-6

 Table 1 Key studies for enteral nutrition in critically ill children
Number of sites, Definition of early
Author, year Population Study design Outcome Secondary outcomes/comments
sample size n EN and late EN

Mikhailov, General PICU 12 sites, Retrospective <48 h, >48 h Mortality: aOR 0.51 (95% CI: Increasing proportion of EN relative
2014, (28) n=5,105 0.34–0.76) to goal calories at 48 h associated
with lower mortality (P<0.001)

Prakash, General PICU 1 site, n=120 RCT <6–24 h, >24 h Median duration of PICU stay: 168 h Mortality: 30% (early EN) vs. 48%
Pediatric Medicine, 2022

2016, (48) (early EN) vs. 143 h (late EN), P=0.41 (late EN), P=0.07

Wong, Acute respiratory 1 site, n=107 Retrospective <24 h, >24 h Mortality: 26.2% (early EN) vs. 73.8% Adequate energy and protein
2017, (3) distress syndrome (late EN) delivery associated with better
outcomes

© Pediatric Medicine. All rights reserved.

Haney, Acute respiratory failure 1 site, n=106 Retrospective <72 h, >72 h Median PICU LOS: 10.7 days (early Median hospital LOS: 22 days (early
2018, (50) EN) vs. 12.9 days (late EN), P=0.001 EN) vs. 28.7 days (late EN), P<0.001

Meinert, Traumatic brain injury 15 sites, n=90 Secondary <72 h, No Improved survival with early EN Improved GOS-E Peds scores at
2018, (51) analysis EN/>72 h (P=0.01) 6 months (P=0.03) and 12 months
of RCT (P=0.04) with early EN

Ong, Extracorporeal 1 site, n=51 Retrospective Not defined Timing of EN initiation: 37 h (survivors) Greater EN energy adequacy was
2018, (53) membrane oxygenation vs. 50 h (non-survivors), P=0.03 associated with better clinical
outcomes

Greathouse, Extracorporeal 1 site, n=49 Retrospective Not defined Any EN by day 5 of ECMO and Adequacy of EN intake by day 5 of
2018, (54) membrane oxygenation mortality: OR 0.37 (95% CI: 0.15–0.96) ECMO was associated with survival

Kalra, Cyanotic heart disease 1 site, n=30 RCT 4–6 h, >48 h Duration of MV: 58 h (early EN) vs. ICU LOS: 179 h (early EN) vs. 229 h
2018, (56) undergoing surgery 89 h (late EN), P<0.05 (late EN), P<0.05

Balakrishnan, Traumatic brain injury 5 sites, n=416 Retrospective <48 h, >48 h Functional outcomes: change in POPC ICU LOS: 1.2 days (early EN) vs.
2019, (52) at ICU discharge 0 (early EN) vs. 2 (late 4.9 days (late EN), P<0.0001
EN), P<0.0001
Hospital LOS: 3 days (early EN) vs.
11 days (late EN), P<0.0001

Mortality: 1% (early EN) vs. 12%

(late EN), P<0.0001

Srinivasan, General PICU 35 sites, n=608 Secondary <48 h, >48 h 90-day mortality: aOR 0.43 (95% CI: ICU-free days: HR 1.26 (95% CI:
2020, (49) analysis 0.24–0.80) 1.03–1.55)
of RCT
Hospital-free days: HR 1.62 (95%
CI: 1.18–2.23)

Ventilator-free days: HR 1.29 (95%

CI: 1.07–1.57)
EN, enteral nutrition; PICU, pediatric intensive care unit; RCT, randomized controlled trial; aOR, adjusted odds ratio; 95% CI, 95% confidence intervals; HR, hazard ratio;
LOS, length of stay; GOS-E Peds, Glasgow Outcome Scale score Extended for Pediatrics; POPC, pediatric overall performance category; ECMO, extracorporeal membrane
oxygenation; MV, mechanical ventilation.

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Page 5 of 12
Page 6 of 12 Pediatric Medicine, 2022

discharge (51,52,59). (63,64,69). The risk increases for children who require
In studies of critically ill children supported with PICU admission, up to 30% present with malnutrition
extracorporeal membrane oxygenation (ECMO) findings (2,43,65,70). Multidisciplinary coordination with a
suggest improved survival with use of EEN (53,54). systematic plan of care is necessary to ensure nutrition
Despite its suggested benefit and evidence in other PICU therapy continues throughout the perioperative period with
populations, use of EEN in children who require ECMO is close follow-up after discharge.
variable and without clear guidelines (53-55). Integral to the success of the surgical encounter are the
Evidence to support EEN initiation in children with Enhanced Recovery after Surgery (ERAS) guidelines (63).
congenital heart disease undergoing cardiac surgery with First introduced in adults, these guidelines have gained
cardiopulmonary bypass is limited but growing. This group momentum in pediatric surgery. ERAS is a multidisciplinary,
constitutes an important cohort of critically ill children multimodal approach to longitudinal pediatric surgical care,
(56,57). Studies suggest use of EN is associated with with overarching principles designed to limit the amount of
decreased duration of mechanical ventilation, PICU length time without nutritional intake, reduce perioperative stress and
of stay and overall improved nutritional outcomes (56,57,60). adjust treatment and therapies that will potentially contribute to
long term caloric and protein deficits (63,66). ERAS guidelines
are to limit variability across the numerous services who care for
Strategies for nutrition delivery in PICU populations
pediatric surgical patients during the hospitalization.
Strategies related to initiation of enteral feeding in critically At the core of the ERAS guidelines are a focus on
ill children must consider the severity of illness, the nutrition and metabolism, while limiting surgical stress
child’s nutritional status, and presence of clear criteria for and minimizing barriers to restoring normal digestion,
monitoring feeding tolerance. absorption and utilization of energy (63). Studies evaluating
Use of a feeding protocol is a strategy that has use of ERAS are limited, yet findings report a reduction
demonstrated positive utility in EN provision for critically in hospital length of stay, decreased time to resume oral or
ill children (25-27), and current feeding guidelines enteral intake and reduced time to return of bowel function
recommended their use (1,6). Additionally, feeding protocol (66,71,72). Children are more sensitive to operative stress,
use is aligned with early feed initiation, minimization of to alterations in thermoregulation and glucose control.
avoidable interruptions and achievement of targeted fluid, They have unique considerations that differ from adults,
energy and protein goals (25-27). Common avoidable therefore use of the ERAS bundle guidelines may be a
interruptions for delivery of EN in critically ill children useful strategy to enhance postoperative care and improve
include real or perceived feeding intolerance, emesis, surgical outcomes (73).
diarrhea, feeding device occlusion or malfunction, and
unplanned procedures (23,58,59,61). Collaboration with
Preoperative considerations
a critical care trained registered dietitian and a focus on
accurate assessment, determination of energy requirements A major aspect to consider in the immediate preoperative
and clear, timely and accurate prescription are additional period are fasting times. Limited glycogen stores make
strategies to successful EN initiation and advancement in children and infants more sensitive to fasting than adults
critically ill children (1,6,29,30,32,62-66). (74,75). The purpose of enteral fasting is to achieve gastric
emptying prior to induction of anesthesia to minimize
the risk of aspiration and subsequent complications (76).
Nutrition considerations in pediatric surgical
Current perioperative guidelines no longer instruct families
critical care
to fast children for prolonged periods prior to surgery (77).
Preparation for surgery begins months in advance with a Instead, preoperative guidelines now recommend an
detailed history, nutrition assessment, and review of growth allowance for clear liquids up to two hours prior to surgery,
parameters to identify and correct derangements and with breast milk and solids permissible until four and six
optimize the child’s health prior to surgical intervention hours, respectively (74,78). Despite this, fasting times
(60,67,68). Malnutrition is an associated independent remain widely variable with reported preoperative median
variable in surgical outcomes, putting these children times ranging from four to 10.5 hours (74,78-80). In the
at increased risk for adverse postsurgical reactions critically ill patient, pre-operative fasting guidelines require

© Pediatric Medicine. All rights reserved. Pediatr Med 2022;5:9 | http://dx.doi.org/10.21037/pm-21-6

Pediatric Medicine, 2022 Page 7 of 12

individualized modification due to gastric dysmotility nausea and vomiting regimen may be needed to support
induced by the illness. the re-introduction of oral or EN (84). Some pediatric
Aligned with the updated preoperative fasting guidelines, postoperative feeding protocols recommend starting
administration of a carbohydrate drink has been used in clear fluids within two hours following surgery in low-
pediatric ERAS protocols. In adults, this approach has risk patients with the goal of starting EN within 24 hours.
been found to maintain glycogen reserves, decrease insulin Progressing the patient to full oral or enteral intake will
resistance and minimize protein breakdown (75,81). Data facilitate the provision of nutrient delivery to mitigate the
suggests carbohydrate drinks may improve comfort and catabolism that occurs with surgical stress and enhance
reduce anxiety and further implies that these drinks do not wound healing.
increase the risk of aspiration, and may facilitate gastric Suboptimal nutritional intake during the postoperative
emptying (81). There is growing evidence suggesting that period, put children at risk for nutritional deterioration
hyperosmotic preoperative bowel prep is not necessary, it causing slow restoration of endogenous protein and delaying
can potentially increase the risk of surgical site infection, recovery (85). Potential postoperative complications such as
wound dehiscence and cause bowel edema leading to gastric infection, inflammation, protein loss and prolonged catabolism
dysmotility and enteral feeding intolerance (75). Planned may extend surgical stress if appropriate interventions such
preoperative nutritional strategies may help maintain as nutrition therapy are not implemented (77). Feeding
metabolic homeostasis and achieve a euvolemic state. Studies interruption with prolonged duration is a known causative
to better understand the impact of these interventions and factor of decreased EN intake in the postoperative patient
their effect on surgical recovery in children are needed. (85,86). Real or perceived feeding intolerance, feeding device
mechanical issues, and preprocedural fasting are commonly
identified reasons for feeding cessation (85).
Operative considerations
The multidisciplinary focus on nutrition and metabolism
In response to surgical stress the body releases throughout the entire perioperative period may positively
catecholamines, cortisol, glucagon and cytokines (82). impact surgical outcomes.
The surgical and anesthesia teams each have a role in
limiting this stress. An anesthetic plan with limited use of
EN for critically ill children on vasoactive
opiates will reduce the incidence of postoperative intestinal
medications
ileus and promote early reintroduction of oral or enteral
feeds. Regional anesthesia is used to decrease the amount Provision of EN to critically ill children who require use
and frequency of postoperative sedatives and anxiolytics of vasoactive medication infusions is variable (86,87). In
and has been shown to reduce the inflammatory and addition to overall clinical status, factors to consider are
metabolic responses while increasing gut motility (83). vasoactive medication infusion dose, known or suspected GI
Intraoperatively, the goal of fluid administration is dysfunction, and evidence of tissue hypoxia with subsequent
euvolemia. Fluid overload potentially has several adverse multiple organ dysfunction syndrome. Gut dysfunction
effects including increase in mechanical ventilation with disruption of the intestinal barrier can occur due to an
days, bowel edema leading to an ileus with intolerance alteration in splanchnic circulation owing to the severity of
of nutrients into the GI tract, and prolonged time to illness, the resuscitation efforts, and the current treatments
mobilization and rehabilitation. Lastly, avoidance of and therapies the child requires (87-90). Data in both adult
prolonged use of unnecessary enteral tubes and drains and pediatric critically ill patients demonstrate safe, well-
(nasogastric tube, or gastric decompression catheters) and tolerated administration of EN while receiving vasoactive
promotes early mobilization and return of gastric motility. medications (4,88,91,92). Recent guidelines for nutrition
therapy in critically ill adults acknowledge that patients may
benefit from EN while receiving vasoactive medications
Postoperative considerations
(30,31).
Following surgery, the major nutritional goal is the The use of vasoactive medications for hemodynamic
restoration of normal GI function allowing nutrient intake. support is often thought to be a contraindication to EN due
If mechanically ventilated, clear metrics of criteria for to hypoperfusion to the gut that can result in mesenteric
extubation should be set. Once extubated, a postoperative ischemia. Uncertainty in adequacy of splanchnic circulation

© Pediatric Medicine. All rights reserved. Pediatr Med 2022;5:9 | http://dx.doi.org/10.21037/pm-21-6

Page 8 of 12 Pediatric Medicine, 2022

and GI perfusion often causes reluctance to feed a gut that guidelines to support provision of nutrition for critically ill
may be compromised (86,93). Alterations in splanchnic children, enable pediatric critical care providers collectively
perfusion can decrease normal function of the GI tract, to appropriately modify care based on each patient’s
causing an increase in oxygen demand, reduced absorption, demonstrated need. Further research is necessary to better
and a decrease in peristalsis. This can increase the risk understand how to improve nutrition therapy in various
for bowel obstruction or perforation which is associated populations of critically ill children.
with increased mortality (87,91). In fact, EN may have a
protective role in preserving gut integrity, by stimulating
Acknowledgments
blood flow to the GI tract, enhancing gastric emptying and
lowering the risk of bacterial translocation (94). Studies Funding: None.
suggest use of the functioning GI tract in patients who
require vasoactive medications is well tolerated and the
Footnote
benefits may outweigh the risks.
The American and European Guidelines for nutrition Provenance and Peer Review: This article was commissioned
therapy in critically ill children recommend EN when safe by the Guest Editors (Lyvonne Tume, Frederic Valla
and appropriate, including those children who require and Sascha Verbruggen) for the series “Nutrition in the
vasoactive medication support (1,6). Retrospective studies in Critically Ill Child” published in Pediatric Medicine. The
children on vasoactive medication infusions of dobutamine, article has undergone external peer review.
dopamine, epinephrine, milrinone, norepinephrine,
phenylephrine and vasopressin who were enterally fed Conflicts of Interest: The authors have completed the ICMJE
suggest the provision of EN is safe and use of vasoactive uniform disclosure form (available at https://pm.amegroups.
medications is not exclusively contraindicated and may com/article/view/10.21037/pm-21-6/coif). The series
overall be beneficial (84,92). “Nutrition in the Critically Ill Child” was commissioned by
A systematic approach including use of a feeding the editorial office without any funding or sponsorship. Dr.
protocol, close monitoring with clear definitions of feeding Srinivasan serves as an unpaid editorial board member of
intolerance is a strategy to employ in critically ill children Pediatric Medicine from Jan 2021 to Dec 2022. The authors
requiring vasoactive medications to optimize nutrient have no other conflicts of interest to declare.
delivery, support GI function and decrease risks that may
ensue due to the patient’s changing clinical status. The Ethical Statement: The authors are accountable for all
lack of RCTs and limited evidence in this area of pediatric aspects of the work in ensuring that questions related
critical care should not be an absolute contraindication to to the accuracy or integrity of any part of the work are
enterally feeding patients who require vasoactive medication appropriately investigated and resolved.
infusions, instead an understanding of the risks and benefits
of EN in these patients is warranted. Open Access Statement: This is an Open Access article
distributed in accordance with the Creative Commons
Attribution-NonCommercial-NoDerivs 4.0 International
Conclusions
License (CC BY-NC-ND 4.0), which permits the non-
Optimizing EN in the pediatric critically ill patient can commercial replication and distribution of the article with
be extremely challenging. The heterogeneity of children the strict proviso that no changes or edits are made and the
by disease entity and the response to stress, age, nutrition original work is properly cited (including links to both the
status and differences in body size require special attention formal publication through the relevant DOI and the license).
to nutrition therapy. All children admitted to the PICU are See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
at increased risk for suboptimal nutrition therapy owing
to competing priorities of care. However, there is ever-
References
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doi: 10.21037/pm-21-6
Cite this article as: Irving SY, Albert BD, Mehta NM,
Srinivasan V. Strategies to optimize enteral feeding and
nutrition in the critically ill child: a narrative review. Pediatr
Med 2022;5:9.

© Pediatric Medicine. All rights reserved. Pediatr Med 2022;5:9 | http://dx.doi.org/10.21037/pm-21-6